MANAGEMENT OF DIABETIC FOOT INFECTIONS & OSTEOMYELITIS

DR. P.C. CHYE Consultant Orthopaedic Surgeon Dept. Orthopaedic Surgery & Traumatology Hospital Kuala Lumpur

DIABETES MELLITUS

Global Prevalence :

2003 : 194 million

2010 : 252 million

2025 : 380 million

PREVALENCE OF DM IN MALAYSIA (Population >30 years)

0.65%

2.10%

6.30%

8.30%

14.90%

1960 1982 1986 1996 2006

Year

Prevalence of Diabetes Mellitus in Malaysia

Prevalence

3rd National Health and Mortality &

Morbidity Survey

22%

08

DIABETIC FOOT INFECTIONS RISK FACTORS

HOST DEFENSE : Neutrophil functions : chemotaxis,phagocytosis, intracellular killing Monocyte & complement functions PERIPHERAL VASCULAR DISEASES : in blood supply needed to heal ulcers and infection SENSORY NEUROPATHY : in appreciation of pain and temperature injuries not noticed, severity underestimated MOTOR NEUROPATHY : anatomical foot deformity abnormal pressure points

ulceration AUTONOMIC NEUROPATHY : sweating, dry & cracked skin portal of bacteria entry

DIABETIC FOOT INFECTIONS - SPECTRUM

Ranges from cellulitis to infected ulcers, abscess, osteomyelitis , wet gangrenes and necrotising fasciitis

40% Mild 30-40% Moderate 20-30% Severe

40-80% Infected

(or suspected)

15-25% Develop Foot Ulcer

7% of Population

Diabetic

49% of diabetic patients with diabetic foot infection will develop infection in the other foot in 18 months

DIABETIC FOOT INFECTIONS THE DEVELOPMENT

Usually precipitated by trauma

Infection may start superficially in an ulcer or crack of the skin but can rapidly progress to involve deeper structures including tendons and bones

The anatomical structures of various compartments of the foot, tendon sheaths, ligaments, fascia and neurovascular bundles tends to facilitate proximal spread of the infection

Inflammation and infection in the foot compartments can cause compartment syndrome vascular thrombosis

DIABETIC FOOT INFECTIONS - PRESENTATIONS

Redness, swelling, discharging sinus/ulcer, gangrene, pain

Diabetic patient may or may not mount a fever, even in the presence of severe infection

50% of patients with a limb-threatening infection do not manifest systemic signs or symptoms leading to underestimation of the presence and severity of infection

The signs and symptoms are masked by neuropathy

Hypotension, tachycardia and severe unexplained hyperglycaemia are however often noted

DIABETIC FOOT INFECTIONS - PROGRESSION

Coexisting metabolic derangements, peripheral arterial disease, poor immune response poor delivery of antibiotics to the infected tissues, reduced access & functions of phagocytic cells to the infected area rapid progression of infection in hours or days & quickly become limb- or life-threatening

DIABETIC FOOT INFECTIONS

These wounds are usually more severe & more complicated to treat than do equivalent infections in persons without diabetes

DIABETIC FOOT INFECTIONS - BACTERIA INVOLVED

Aerobic Gram +ve cocci, esp (Staphylococcus aureus) are the predominant pathogens

In chronic ulcers or in patients who have recently received antibiotic therapy may be infected with Gram ve rods

In those with foot ischaemia and gangrene may have obligate anaerobic organisms

- Staphylococcus aureus 45%

- Streptococcus sp. 35%

- Enterococcus sp. 29%

- Staphylococcus epidermidis 23%

- Proteus mirabilis 26%

- Pseudomonas aeruginosa 16%

- Peptostreptococcus sp. 22%

- Diphtheroids 19%

- Bacteroides sp. 16%

Gram positive cocci

Microbial complexity

Microbial burden

Clinical risk

1 2 3 4

Anaerobes

Aerobic Gram-negative rods

Prior Rx

Necrosis

Depth

Severity

Limb-threatening infections are often polymicrobial

MULTIRESISTANT BACTERIAL INFECTIONS

Diabet Met 2004 Jul;21(7) : 710-5

Diabetic foot ulcer and multidrug-resistant

organisms: risk factors and impact. Hartemann-Heurtier A, Robert J, Jacqueminet S, Ha Van G, Golmard JL, Jarlier V, Grimaldi A.

Detected in 1/3 of patients with

previous history of hospital

admission for the same wound

Detected in 25% of patients

with osteomyelitis

ALMOST 50% of Staph aureus isolated are MRSA !

Clinical Microbiology & Infection- October 2005

Prevalence of methicillin-resistant Staphylococcus aureus in infected and uninfected diabetic foot ulcers

TIMELINE OF STAPHYLOCOCCAL RESISTANCE

1940 1950 1960 1970 1980 1990 2000 2010

Penicillin-resistance

GISA

CA-MRSA

VRSA

Sporadic MRSA Epidemic MRSA

DIABETIC FOOT INFECTIONS TREATMENT STRTEGIES

Require attention to both local & systemic issues

DIABETIC FOOT INFECTIONS -COMPREHENSIVE MANAGEMENT

TREAT THE ULCER & INFECTION, GET THE WOUND TO HEAL, PREVENT RECURRENCE

TREAT THE DIABETES, ASSOCIATED SYSTEMIC PROBLEMS & OVERCOME THE UNDERLYING PATHOLOGY

LOC

AL

ISSU

ES

SYST

EMIC

ISSU

ES

+

AT THE SAME TIME

DIABETIC FOOT INFECTIONS - MULTIDISCIPLINARY TEAM APPROACH

Comprehensive management of these patients requires care of a finely-tuned multidisciplinary team for medical stabilization, surgical debridement, antibiotic selection, vascular reperfusion, wound care, podiatric care, orthotic care, nutrition support, rehabilitation and delayed reconstruction to achieve functional limb salvage

EVALUATION AT 3 LEVELS

1 The patient as a whole 2 The affected limb or foot 3 The infected wound To determine : - presence, type, extent and severity of infection - pathogens involved - presence of any systemic consequences of infection - contribution of vascular disease / neuropathy - altered foot biomechanics that contributes to the cause of the wound ( and thus, its ability to heal )

DIABETIC FOOT INFECTIONS - INITIAL ASSESSMENT AND INVESTIGATIONS

BLOOD INVESTIGATIONS : - Full blood count - Erythrocyte Sedimentation Rate (ESR) - C- Reactive Protein (CRP) - Random / Fasting Sugar Levels - Glycosylated Haemoglobin - Renal Profile - Serum Albumin

DIABETIC FOOT INFECTIONS - INITIAL ASSESSMENT AND INVESTIGATIONS

EXAMINE THE FOOT : - Palpation/probing for fluctuance & tunneling wounds/ ulcer (deep

infection) - a clinically infected ulceration probes to bone 89-95% osteomyelitis - Blood supply : Dorsalis Pedis , Posterior Tibialis & Popliteal pulses.

Ankle-Brachial Systolic Index ( ABSI ), Doppler, Evidence of ischaemia & gangrene

- the degree of impaired limb perfusion significantly reduce the chances of wound healing, increases the overall severity of infection and risk of amputations

- Sensation --- Neuropathy pain in an insensate foot means severe infection

- Deformities & Abnormal Pressure Points

DIABETIC FOOT INFECTIONS - INITIAL ASSESSMENT AND INVESTIGATIONS

TAKE AN X-ray : - Osteomyelitis - Gas Gangrene - Presence of Foreign Body - Osseous deformities / fractures / dislocations MRI is more sensitive and specific, especially for extent of soft tissue involvement

DIABETIC FOOT INFECTIONS INITIAL MANAGEMENT

IDENTIFY THE ORGANISMS INVOLVED : - Send appropriately obtained speciments for culture before

starting empirical antibiotic therapy - Soft tissue or bone speciments obtained by biopsy, curettage, or

aspiration are preferable - Superficial swab cultures of infected ulcers often complicate

evaluation of the infection - Definitive antibiotic therapy will be based on C&S results from intra-op cultures

Initial treatment in a previously untreated patient with a non-limb-threatening infection is focused on Staphylococcus and Streptococcus sp

Initial treatment of limb-threatening infections requires broad-spectrum antibiotics covering Staph aureus, group B Streps, other Streptococcus sp., enterobacteriaceae & anaerobes

DIABETIC FOOT INFECTIONS INITIAL MANAGEMENT ANTIBIOTIC SELECTION

Characteristic odours or history of resistant bacterial infections affect initial antibiotic choices

Antibiotic vary in how well they achieve effective concentration in the infected diabetic foot -- affected by the arterial blood supply to the foot & pharmacodynamic properties of the drug

DIABETIC FOOT INFECTIONS INITIAL MEDICAL MANAGEMENT

The degree of end organ dysfunction affects multiple aspects of medical and surgical management

Antibiotic dosing adjustment issues, poor cardiac function, hyperglycaemia, ketoacidosis, dehydration, hyperosmolality, electrolyte imbalance, renal insufficiency, anaemia, poor limb perfusion, immunosuppression, poor nutrition, poor healing potential often coexist

The goal of medical management is to regulate and normalize the metabolic and haemodynamic derangements and to prevent further decompensations

STABILIZE / RESUSCITATE THE PATIENT

Restore fluid and electrolyte balances, correct anemia, hyperglycaemia,

hyperosmolarity, acidosis &

treat other exacerbating

disorders

Optimize treatment of other

medical illnesses : ischaemic

heart disease, heart failure,

renal impairment etc

May need resuscitation

eg sepsis, ketoacidosis

DETERMINE THE NEED FOR SURGERY

When a non-healing infected diabetic foot ulcer is worsening despite adequate wound care and cultured-directed antibiotics, urgent surgery is needed

Emergency surgical intervention :

Life- or limb-threatening infection

eg. Necrotising fasciitis

Gas gangrene

Critical limb ischaemia

Deep abscess

OVERVIEW OF SURGICAL MANAGEMENT OF INFECTED DIABETIC FOOT

To achieve a healed wound & prevent

major amputation of the leg :

Darinage of pus, remove necrotic soft

tissue & bone + creating a healthy

wound bed

Limb reperfusion

Soft Tissue Cover

Correct deformity, relieve pressure areas

Restore stability, alignment & function

Reduce risk of reulceration & subsequent amputation

SUCCESSFUL SALVAGE

Incision & drainage Debridement Sequestrectomy Disarticulation Ray Amputation

DIABETIC FOOT INFECTIONS INITIAL SURGICAL DEBRIDEMENT

After patient is medically stabilised

Must be timely and aggressive Remove all sloughs, necrotic and marginal-looking tissues, dead bones, drain all pus, explore all sinus tracts Exposed tendons should be excised if proximal migration of infection is suspected

Exploration is done to determine involvement of fascial planes

The degree of intra-operative bleeding must be assessed Aims to reduce the bacterial load in the wound, create a healthy environment

to restore the physiologic processes of tissue repair and healing

Changes stubborn non-healing chronic wounds into acute wounds

Deep tissue & bone : C&S HPE ( if osteomyelitis suspected)

Crucial to successful control of infection and must be done as soon as possible

In severe infections, general anaesthesia is often needed as the depth of infection and fascial spread may be extensive

ANTIBIOTICS THERAPY

OFTEN INSUFFICIENT WITHOUT APPROPRIATE WOUND CARE

TREAT THE INFECTION, DO NOT STERILISE THE WOUND

Based on culture & sensitivity results, depth and severity of infection CONTINUED UNTIL RESOLUTION OF INFECTION, NOT UNTIL THE WOUND HAS HEALED

DIABETIC FOOT INFECTIONS --- WOUND BED PREPARATION

Converting a chronic wound into a wound with the potential to heal

Involves debridement, control of infection and inflammation, moisture control, excision of wound edges and callus

"TIME - "T" refers to the need to remove necrotic and diseased Tissue - "I" indicates the need to control bacterial burden and Infection - "M" refers to restoration of Moisture balance - "E" stands for the healing Edge, which is the point at which the wound is optimally primed for healing

DIABETIC FOOT INFECTIONS --REPEATED SHARP DEBRIDEMENT

Repeated sharp debridement is done until all necrotic tissues and bone + biofilms are removed

Stimulates production of growth factors and proliferation of collagen and fibroblasts

A healthy wound bed is created for granulation tissue to grow and wound to heal

REPEATED DEBRIDEMENT - ULTRASONIC DEBRIDEMENT

Use of low frequency cavitational ultrasound to debride away dead tissues, leaving healthy and granulation tissue intact

Also removes bacteria and biofilms

Sterile saline solution transfer the ultrasonic energy to the wound where tiny vibrating gas bubbles and cellular level fluid movement separates dead from healthy tissues

Safe, cost effective , painless alternative to painful sharp debridements

Low-frequency ultrasound has been shown to have cellular-level physical effects, known as cavitation and microstreaming, that can promote healing

Cavitation is the formation and oscillation of microscopic bubbles, which expand and collapse as they resonate with the ultrasound frequency

Acoustic microstreaming is the physical force of sound pressure waves that can displace small molecules and move fluids along and/or through cell membranes.

REPEATED DEBRIDEMENT - HYDROSURGICAL DEBRIDEMENT

Versajet Hydrosurgery System ( Smith & Nephew) - utilises a high-pressure jet of sterile saline that travels

parallel to the wound surface

- This high-speed jet creates a Venturi effect that enables the surgeon to simultaneously hold, cut and remove tissue, while irrigating and aspirating the wound, with a single instrument

Enables rapid debridement, likely to result in shorter procedure times

Clean wounds potentially reduce the number of required debridement procedures

Single device technique - combining lavage and sharp debridement instrumentation

Multiple tip configurations enhance procedural flexibility

REPEATED DEBRIDEMENT - Maggots Debridement Therapy

Sterile larva of the greenbottle fly is applied to the wound for 2-3 days

Necrotic tissues are eaten away

In late 1920s, William Baer from Johns Hopkins University, used maggots to treat children with osteomyelitis and soft tissue infections

Successfully performed by thousands of physicians throughout 1930s, but was supplanted by the new antibiotics and surgical techniques during World War II

In 2004, FDA allowed the production and marketing of the Phaenicia sericata larvae

In 2006, approx 50,000 treatments were applied to wounds using maggots

Low cost, simple, safe, ideal when surgical debridement is not the optimal choice

REPEATED DEBRIDEMENT - ENZYMATIC DEBRIDEMENT

Involves application of a cream or ointment to the wound. The action of the chemicals or enzymes contained in the cream work to loosen the dead tissue, which is then manually removed Fast acting

Minimal or no damage to healthy tissue with proper application.

May be used as the primary technique for debridement in some cases when surgical debridement is not feasible owing to bleeding disorders or patient is not fit for surgery

Combined therapy, such as initial surgical debridement followed by serial debridement using an enzymatic agent is effective for many patients with chronic, indolent, or nonhealing wounds

POST- DEBRIDEMENT SOFT TISSUE COVER

Presence of large soft tissue defect after surgical debridement often makes primary closure difficult

When possible, the least invasive methods of coverage are employed

eg. Delayed primary closure

Vacuum assisted closure

However, many wounds are not amenable to delayed primary closure and require plastic surgical techniques

- Split Skin Graft

- Local and Pedicle Flaps

- Free Flaps

VACUUM ASSISTED CLOSURE

Using a vacuum source to draw fluid out of the wound to accelerate debridement and promote healing

Not for acutely ischaemic foot, tumour wound

Special precaution : patient on anticoagulant

Wound bed preparation prior to initiation of treatment

Optimal level of negative pressure ~125mmHg

Most effective if applied in a cyclical pattern 5 mins on, 2 mins off

Advantage : - cheap - Ideal for difficult- to heal wounds Disadvantages : - restricts patient mobility

DIABETIC FOOT INFECTIONS -- CELLULITIS

9 times more frequent in diabetic compare to nondiabetic patients

Infection is confined to the dermal and subcutaneous layers

Commonly caused by Group A Streps & Staph

Entry : skin cracks, fissures, blister, insect bites

Antibiotics

DIABETIC FOOT INFECTIONS - OSTEOMYELITIS A difficult problem to treat & heal

The combined effects of peripheral vascular disease, neuropathy, and repetitive trauma produce complex lesions with exposed bone, surrounding cellulitis, and soft tissue gangrene

Plain x-rays, gallium scan, MRI

Bone culture

DIABETIC FOOT INFECTIONS - OSTEOMYELITIS

Diabetes Care August 2006 vol. 29 no. 8 1727-1732

A Clinico-microbiological Study of Diabetic Foot Ulcers in an Indian

Tertiary Care Hospital Ravisekhar Gadepalli, MSC; Benu Dhawan, MD; Vishnubhatla Sreenivas, PHD; Arti Kapil, MD1; A.C. Ammini, MD; Rama Chaudhry, MD

All patients had Wagner 3-5 ulcers 62.5% had associated osteomyelitis

DIABETIC FOOT INFECTION - OSTEOMYELITIS

If osteomyelitis is confirmed from initial deep cultures or histopathology, further aggressive resection of all affected bone is warranted

DEBRIDE ALL DEAD BONE & SOFT TISSUE till viable, bleeding bone & soft tissue

Staph aureus penetrates and survives in bone cells

* BONE PENETRATION OF ANTIBIOTICS * Fluoroquinolones ( ciprofloxacin, ofloxacin, moxifloxacin), Fucidic acid

NECROTISING FASCIITIS IN DIABETIC

Incidence on the rise

70% of patients are diabetic

MEDICAL & SURGICAL EMERGENCY !

Highly fatal ( overall morbidity & mortality : 70-80% )

Group A hemolytic streptococci ( Strep pyogenes ) and

Staph aureus, alone or in synergism, are frequently the initiating infecting bacteria

However, other aerobic and anaerobic pathogens may be present, including Bacteroides, Clostridium, Peptostreptococcus, Enterobacteriaceae, coliforms, Proteus, Pseudomonas, and Klebsiella.

Poor prognostic factors : advanced age, poor glycaemic control, long duration of diabetes & delayed referral

NECROTISING FASCIITIS

Progressive, rapidly spreading infection along the deep fascia plane & extensive necrosis of the subcutaneous tissues & muscle without a corresponding necrosis of the overlying skin until much later

Early features : Fever, pain, tachycardia, swelling, induration, cellulitis

Late features : Severe pain & tenderness disproportionate to skin changes, skin discolouration ( purplish black ), blister or bullae, crepitus, septicaemic shock, multiorgan failure

X-rays : subcutaneous gas

Antibiotics

Extensive surgical debridement & fasciotomy : delay for 24 hours mortality

THE ISCHAEMIC DIABETIC FOOT

UNLESS THERE IS ADEQUATE REPERFUSION OF THE FOOT / LEG, ANTIBIOTICS TREATMENT

AND SURGERY WILL FAIL & AMPUTATION WILL BE NEEDED

SURGERY IN THE DIABETIC FOOT

Historically, diabetic foot surgery was largely done in the presence of acute infection or when in need of amputation

With better understanding of the pathophysiology of diabetic foot disease, we have began to recognize the importance of elective diabetic foot surgery in helping patients to stay active and ulcer free

CLASSIFICATION OF SURGERY IN THE DIABETIC FOOT

CLASS PURPOSE EXAMPLES I ( Elective ) For painful deformities in patients Realignment osteotomies, without neuropathy or open wounds tendon balancing procedures, II ( Prophylactic ) For prevention of ulceration in patients arthrodeses & Charcot with neuropathy but no open wounds reconstructions III ( Curative ) To assist healing of ulcers in patients Partial or complete removal of with neuropathy bone such as metatarsal head, sesamoid, accessory bone, exostosis, calcanectomy, soft tissue cover / reconstructions IV ( Emergent / To arrest / limit progression of acute Amputations, debridements, Ablative ) infection, eliminate infected and incision and drainage necrotic tissue Armstrong DG, Lavery LA, Frykberg RG. Validation of a diabetic foot surgery classification. Int Wound J 2006;3(3): 240-246

ELECTIVE & PROPHYLACTIC SURGERY FOR THE DIABETIC FOOT

GOALS :

1) Stability

2) Realignment

3) Platigrade foot amendable to bracing or accomodation

4) Reduction of pressure points / surgical offloading

ELECTIVE / PROPHYLACTIC SURGERY

FOREFOOT :

HALLUX and FIRST METATARSALPHALANGEAL JOINT : - SESAMOIDECTOMY / EXOSTECTOMY

- HALLUX INTERPHALANGEAL ARTHROPLASTY / ARTHRODESIS

- RESECTION OF FIRST METATARSAL HEAD

- OSTEOTOMIES OF THE PHALANX AND FIRST METATARSAL LESSER DIGITS : - LESSER METATARSAL OSTEOTOMIES : Shortening osteotomy Elevating osteotomy - LESSER METATARSAL HEAD RESECTION

ELECTIVE / PROPHYLACTIC SURGERY

MIDFOOT :

- EXOSTECTOMY

- REALIGNMENT MIDFOOT OSTEOTOMIES + ARTHRODESIS

- single plane vs multiplane

REARFOOT : - TRIPLE ARTHRODESIS

- REALIGNMENT CALCANEAL OSTEOTOMIES

- TALECTOMY + TIBIAL-CALCANEAL ARTHRODESIS

- CALCANECTOMY ( partial / total )

OPTIMIZE THE HOST Correct and reverse all correctable negative factors on wound healing : - Anemia - Diabetes - Heart Failure - Malnutrition - Smoking - Steroid - Vitamin deficiency - Uraemia

FORMULATE A WOUND CARE PLAN Optimal wound care is crucial for healing but it is not the only way to treat the diabetic foot ulcer

Infection complicates treatment of a diabetic foot ulcer, making a more aggressive wound care strategy necessary

One particular dressing should not be used for all stages of wound

A long process time, patience, perseverence -- Dedicated team of doctors and nurses Problems to be addressed in DFU : -- Exudate, bacterial load, slough, granulation

CHOOSING THE APPROPRIATE DRESSING

INFECTED : surgical debridement + silver dressing

EXUDATIVE : absorptive dressing

eg. Hydrofibres, Alginates,

Composite dressings,

Foam dressings

SLOUGHY : surgical / enzymatic /

maggot debridement

DRY : Hydrogels

SAVING EVERY LEG ? Reducing the number of lower extremity

amputations is a goal for all doctors caring for patients with diabetes

However, the numbers of limb-threatening infections continue to rise each year

Failures in limb salvage attempts do occur

These failures result in multiple trips to the operating room, significant potential morbidity and prolonged disability

AMPUTATION

Somewhere in the world, a leg is lost to diabetes every 30 seconds

Diabetics are 40x more likely to undergo amputation of the leg than non-diabetics

>85 % of amputation begins with a foot ulcer

Those who undergo a lower limb amputation have up to 30% chance of undergoing similar amputation on the contralateral limb within 3 years and up to 50% chance in 5 years

Mortality rate post amputation: 11-41% after 1 year 20-50% after 3 years 39-68% after 5 years

Two goals : ABLATION + RECONSTRUCTION

refashioned the viable residual limb so that an appropriate prosthesis may be fitted to assist functional mobility

AMPUTATION

STRAUSS WOUND GRADING SCORE

VARIABLES 2 1.5 1 0.5 0

PERFUSION

DEPTH

SIZE

INFECTION

WOUNDBASE

Warm

Skin & sub-Q

< thumb

Clean & contam.

Red

Cool

Musc & tendons

Thumb fist

Cellulitis

Yellow-white

Cold

Bone & Joint

>fist

Septic

Black

=8 0% amputation

MINOR AMPUTATIONS :

- Disarticulation

- Ray amputation

- Midfoot amputation

- Syme amputation

MAJOR AMPUTATIONS :

- Below knee amputation

- Above knee amputation

- Hip disarticulation

ENERGY CONSUMPTION AND AMPUTATION LEVEL

AMPUTATION LEVEL % ENERGY BEYOND

BASELINE

Long BKA 10

Medium BKA 25

Short BKA 40

Bilateral medium BKA

41

Average AKA 65

Miller; Orthopaedic Review: Pg. 218.

AFTER AMPUTATION .

Specialty diabetic foot clinic : recurrence rate 25-80%/year

Self-monitoring

- to identify signs of disease and precursors to injury

- many diabetic patients with a high risk for ulceration cannot see

their feet ! ( obesity, limited joint mobility, visual impairment )

- by the time patients in this study were able to visualize areas of

concern, it was too late, and an ulceration had already developed

Self-care

CHALLENGE : PREVENTING RECURRENCE

CHALLENGE - PATIENTS

EDUCATION & SUPPORT

PERCEPTION & BEHAVIORAL

CHANGE

Overcoming : - Ignorance / Misconception - Fear - Denial - Uncooperativeness - Social problems

Increase awareness of :

- DM & its many consequences - Methods of care & support available

CHALLENGE THE OLD DIABETIC PATIENTS DIFFERENT FROM THE YOUNGER PATIENTS : Poorer limb perfusion

Poorer healing / tissue regeneration

Weaker immune defence

Comorbidities ++

Soft tissue fragility / osteoporosis

Poor nutrition

Poor vision / memory / senility

Limited mobility

Social and financial support problems

Dependant, poor self care, neglect

NURSING HOME PROBLEMS

Two-thirds of elderly patients undergoing amputation do not return to independent life

CHALLENGE HEALTHCARE PERSONNEL

Organisation : WOUND CARE TEAM - 70% of wound dressings are applied by the bedside

nurse, NOT the wound care specialists

Training ( Knowledge & Skills ) :

- Train more people

- Keep in touch with the latest development - Learn what to do, what not to do, how to do it

Early detection & referral :

- Educate & build a positive working relationaship with primary health care

providers

Budget & allocation

CHALLENGE HEALTH CARE SYSTEM

Although there have been many advances in the management of

the diabetic foot, it remained a major global public health

problem

Where have we failed ?

Health Care Policy ?

Health Care Budgeting ?

Health Care Organisation ?

Policy Implementation ?

What needs to be done ? Present ? Future ?

What about the poorer countries and their people ?

CHALLENGE - RESEARCH

FROM THE BENCH TO THE BEDSIDE - integration of resources into a

coordinated effort and monitoring

pathway to bring products of research

and technology to the patients

FUTURE OF DIABETIC WOUND CARE

Narrowing gap between basic science and clinical application

Necessary to understand the complex interactions of various physiologic components in wound healing

SMART BIOACTIVE DRESSING -- that responds to the needs of the wound by releasing factors needed for healing

STEM CELLS as a potentiator of healing by

replacing or activating senescent cells in the wound eg. Bioengineered skin

OVERALL MANAGEMENT

PREVENTION ! PREVENTION ! PREVENTION !

Early detection and intervention

Medical management of diabetes and comorbid conditions

Targeted antibiotic coverage of infection

TEAM EFFORT

Wound care and dressing, off-loading / pressure relief

Adjuvant therapies (eg. Hyperbaric O2 ) & Nutrition

Post-op follow-up, podiatric care / foot wear and orthoses

PREVENT RECURRENCE !

Doctor treating a foot ulcer : 17th Century, after David Teniers the younger

THANK YOU